We often think of mental health as something controlled by the brain. But it actually depends on a delicate balance of brain chemistry, physical health, life stressors, genetics and experiences.
“Our experiences and physical health can change the brain, its structure and neuroconnections. It’s like a dialogue between our behavior and what we learn,” says Debra Kaysen, a clinical psychologist and professor of psychiatry and behavioral sciences at Stanford University Health Care.
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When any one aspect of our mental health is out of alignment, mental illness can develop. “It’s not a result of shortcomings or someone being flawed. A lot of people face challenging life situations or circumstances,” explains Lindsey McKernan, a clinical psychologist and associate professor in the department of psychiatry and behavioral sciences at Vanderbilt University Medical Center. “You might have a genetic vulnerability, or you might have repeated exposure to trauma or violence that can increase the risk for developing mental illness."
Mental illness is exceptionally common in the United States. The National Institute of Mental Health reports that 1 in 5 adults in the U.S. (57.8 million in 2021) lives with a mental illness.
According to 2020 figures, the most recently available data, from the National Alliance on Mental Illness:
- 19.1% (48 million) of American adults live with anxiety disorders.
- 8.4% (21 million) of American adults experience a major depressive episode.
- 3.6% (9 million) of American adults have post-traumatic stress disorder.
- 2.8% (7 million) of American adults live with bipolar disorder.
- 1.4% (3.5 million) of American adults have borderline personality disorder.
- 1.2% (3 million) of American adults live with obsessive-compulsive disorder.
- Less than 1% percent (1.5 million) of American adults live with schizophrenia.
Impact of the COVID-19 Pandemic
Since the COVID-19 pandemic began in 2020, rates of mental health issues have increased. The American Psychological Association, for instance, reports that "rates of anxiety and depression among U.S. adults were about four times higher between April 2020 and August 2021 than they were in 2019."
Substance use increased during this time, and it has had devastating effects on some people. A March 2023 report from the Kaiser Family Foundation notes that drug overdose deaths increased by 50% during the pandemic. These increases were more pronounced for people of color compared to white people.
Likewise, excessive drinking increased during the pandemic, with alcohol-induced deaths climbing by 38%, KFF reports. These rises have hit the American Indian and Alaskan Native communities especially hard.
Finally, deaths by suicide increased, particularly among adolescent females. KFF reports that 30% of adolescent females seriously considered attempting suicide in 2021, compared to 14% of their male peers. Deaths from suicide also climbed, and some may be misclassified as overdoses.
Recent increases in mental illness also appear to be affecting specific populations, including:
- People who've had COVID-19, particularly those who were in the hospital or intensive care due to severe symptoms.
- Health care workers.
- Young adults.
- People who are Hispanic or Black.
- Unpaid caregivers for adults.
All of this comes with a high price tag, with estimates ranging from nearly $200 to $300 billion annually in lost work output across the country. One 2019 study estimated that the lifetime cost of serious mental illness for an individual clocks in at $1.85 million.
Carmen Katsarov, a social worker and executive director of behavioral health integration with CalOptima Health, a community-based health plan that serves vulnerable residents in Orange County, California, notes that many risk factors can contribute to the development of a mental health disorder. These include:
- Family history.
- Childhood abuse or neglect.
- Adversity in early life, such as poverty, food insecurity or lack of adequate housing.
- Traumatic life events, such as sexual or physical assault.
- Chronic medical conditions, such as diabetes or dementia.
- Acute medical conditions, such as a heart attack.
- Alcohol and drug use.
- Social or situational stressors, such as financial stress, death of a loved one, divorce or a loved one’s incarceration.
Cheryl Carmin, a psychologist and clinical professor of psychiatry and behavioral health at the Ohio State University Wexner Medical Center and the Ohio State University College of Medicine in Columbus, notes that there’s rarely just one cause for any mental health disorder.
“There may be both biological and environmental influences," she explains. "A family history of one or more of these conditions may suggest an underlying genetic predisposition, but that does not imply that if a family member is anxious or depressed that everyone in the family will be so affected.”
What’s more, there’s the question of nature versus nurture; if you were raised in a family where mental health issues were present, did you learn those behaviors through exposure and observation, or do they have a genetic cause?
“For example, if a parent is anxious about public speaking, warning their child to not be nervous when the child has to give a presentation about their summer vacation to their kindergarten class may alert the child to this being something to be afraid of,” Carmin notes.
Some of the more common types of mental health disorders include:
More than just feeling blue, depression can be a chronic, debilitating condition. It may be triggered by situational factors, such as a major trauma, or by chronic exposure to violence or poverty. There's also a genetic component to it: If you have family members who've had depression or other mental illnesses, you may be more likely to experience it.
Depression symptoms last more than two weeks and may include:
- Feelings of sadness, worthlessness and despair.
- A loss of interest in activities that used to provide pleasure.
- Increased isolation.
- Changes in sleep patterns, such as sleeping too much or too little.
- A decreased libido.
- Loss of energy and fatigue.
- Changes in appetite that may lead to unintended weight gain or loss.
- A feeling of being really keyed up or slowed down.
- Self-harming or self-destructive behaviors.
- Feeling worthless or guilty.
- Brain fog, difficulty concentrating or staying focused and difficulty making decisions.
- Suicidal thoughts. “This could be thoughts of death, ideas about suicide without a plan, an active suicide plan or a suicide attempt,” McKernan says.
Katsarov says that “physical symptoms can also be present with anxiety and depression,” and these may include:
- Back pain.
- Stomach issues.
- Racing heart.
- Trembling hands or fidgeting.
- Sweating.
- Other unexplained physical aches or pains.
The good news is that treatment for depression often works well: The American Psychiatric Association reports that 80% to 90% of people respond well to various therapies. These can include:
- Cognitive behavioral therapy. This is a form of talk therapy that redirects negative thoughts and teaches coping skills. “CBT has a strong track record for effective outcomes for treating these disorders,” Carmin says.
- Group therapy. “Many people can benefit from group therapy as it provides a forum to share experiences with others who are also experiencing similar struggles,” Katsarov notes.
- Antidepressant medications. These boost brain chemicals involved in controlling mood.
- Electroconvulsive therapy. This treatment involves doses of electrical currents administered to the brain while a person is under anesthesia.
- Transcranial magnetic stimulation. This treatment uses pulses of magnetic fields to stimulate the part of the brain that controls mood.
- Ketamine. A nasal spray version of the anesthetic ketamine, called esketamine (Spravato), is for treatment-resistant depression only.
- Exercise. “With mild-to-moderate depression, exercise on its own – without medication – can be highly effective,” Kaysen says.
“In addition, many people benefit from adding other approaches, including meditation and acupuncture,” Katsarov says.
Anxiety disorders often occur alongside depression. Carmin says that “anxiety disorders is a relatively broad category including several individual diagnoses.”
Different types of anxiety disorders can bring about different symptoms, but common symptoms include:
- Frequently feeling nervous, tense, restless or on edge.
- Irritability.
- Being easily fatigued.
- Difficulty concentrating or focusing on anything other than the current worry.
- Difficulty sleeping.
- An inability to quell worrying thoughts and feelings.
- Fear of disapproval or a negative evaluation by others.
- Avoidance of social settings.
Anxiety can also be associated with panic attacks or brief periods of intense, acute surges of anxiety accompanied by physical and emotional symptoms, such as:
- A sense of impending doom or losing control.
- An elevated heart rate and rapid breathing.
- Sweating or trembling and feeling nauseated, weak or tired.
- Feeling dizzy, lightheaded or faint.
There are several types of anxiety disorders, including:
- Generalized anxiety disorder. This disorder is characterized by constant anxiety about most everything and often occurs alongside depression.
- Panic disorder. This includes repeated panic attacks that feature chest pain, rapid heart rate, hyperventilation and an intense feeling of impending doom.
- Social anxiety disorder. Features of this disorder include high levels of anxiety or debilitating feelings of embarrassment when placed in social situations.
- Phobias. A phobia is an intense fear related to a specific trigger, such as heights or spiders.
Like depression, anxiety disorders are often treated with a combination of anti-anxiety or antidepressant medications and talk therapy.
Treatments for anxiety include:
- Psychotherapy. This often includes cognitive behavioral therapy. “You may work one on one or in a group setting with a therapist to understand how your thoughts, feelings and behaviors may be contributing to your anxiety patterns and to learn specific skills to manage them,” McKernan says.
- Exposure therapy. For a particular phobia, you may work with a therapist to identify what it is you’re afraid of and then gradually learn skills to manage it. “You gently expose people to anxiety cues in a safe or clinical setting,” Kaysen explains. For example, if you have a phobia of needles, your therapist might ask you to look at pictures of needles alongside a person who doesn’t look distressed. “Eventually, you’ll have the person handle a syringe or hold a needle up to the arm. You stay with that cue until it’s not as scary,” Kaysen says.
- Medications. These may include benzodiazepine drugs for short-term relief or antidepressants for long-term relief.
OCD is a condition characterized by unwanted, recurring thoughts (obsessions) or behaviors (compulsions).
Obsessions may include:
- Thoughts of aggression.
- Taboo thoughts about sex or religion.
- Worries about germs and contamination.
Compulsions may include:
- Frequent hand-washing.
- Arranging things in a certain order.
- Repeatedly checking on things to make sure they’re OK (like a stove that’s turned off).
- Motor tics, such as blinking or shoulder shrugging.
Treating OCD often involves:
- Talk therapy, such as cognitive behavioral therapy or habit reversal training.
- Medication, such as selective serotonin reuptake inhibitors, or SSRIs.
- Transcranial magnetic stimulation.
Bipolar disorder, sometimes referred to as manic depression, is characterized by extreme mood swings from depressed to manic, with a decreased need for sleep. “It’s dramatic: Someone in a manic bipolar episode may sleep less than four hours per night for over a week,” McKernan says.
Bipolar disorder is classified into several types, including:
- Bipolar I, which is the most severe.
- Bipolar II, which is less severe than bipolar I.
- Cyclothymia.
When a person with a bipolar disorder experiences a manic episode, symptoms may include:
- Inflated self-esteem or grandiosity.
- Impulsive behavior, such as excessive risk-taking (examples include gambling and sexual promiscuity).
- Excessively elevated mood.
- Racing thoughts and talking very quickly.
- Extreme euphoria.
- Delusions.
- Irritability.
- High levels of energy.
During depressive periods, people with bipolar disorders may experience:
- Lethargy and a loss of interest in subjects and activities that formerly provided pleasure.
- Feelings of profound depression.
- Loss of motivation and an inability to keep up with the normal activities of daily living.
- Changes in sleep or appetite.
- Suicidal thoughts and actions. “The suicide risk with bipolar disorder is substantially increased,” McKernan says.
To be diagnosed with a mood disorder like bipolar I or II, a person must meet stringent clinical criteria and experience the cycle of symptoms for up to two years or more, depending on the diagnosis.
Once a diagnosis has been made, mood disorders can often be managed with a combination of talk therapy and certain medications, including powerful mood stabilizers, antipsychotics, antidepressants and sleep aids.
PTSD is an ongoing difficulty in coping with exposure to trauma. This condition can be caused by a single event, such as sexual assault or military combat. Complex PTSD is a condition caused by chronic exposure to trauma, such as chronic physical abuse.
In either case, symptoms include:
- Unwanted, repeated, vivid flashbacks or nightmares of the event or events.
- A need to avoid triggers that are reminiscent of the traumatic event(s).
- Feelings of detachment from others.
- Anger, sadness, fear, guilt or shame.
- Distorted beliefs about the self, such as poor self-esteem or perceptions of not being deserving or good enough.
- Reactive symptoms, such as difficulty sleeping or concentrating, reckless behavior or irritable outbursts.
- Persistent depression and suicidal thoughts (in complex PTSD).
PTSD treatment can include:
- Cognitive behavioral therapy, such as prolonged exposure or cognitive processing therapy.
- Guidance to manage triggers, such as eye movement desensitization and reprocessing. EMDR is a treatment that involves directing eye movements while talking about traumatic experiences.
- Specific therapies like prolonged exposure or cognitive processing therapy.
- Antidepressant medications.
- Virtual reality. This helps people with PTSD to experience a particular event, come to grips with it and reprogram the part of the brain responsible for unpleasant feelings.
Schizophrenia is a severe psychiatric disorder characterized by hallucinations and psychotic episodes. It can be a terrifying disease for the people who have it, as well as their loved ones. People with schizophrenia interpret reality differently than other people who don’t have the condition, and the disordered thinking and erratic or bizarre behavior patients exhibit can greatly interfere with normal activities of daily living.
Symptoms often begin in the mid-to-late teenage years through the 20s and may include:
- Problems with thinking and cognition.
- Erratic behavior or emotions.
- Delusions and hallucinations.
- Disorganized speech.
- Disorganized or abnormal movements and behaviors.
- Extreme agitation and irritability.
- An inability to attend to personal hygiene and other functions of normal living.
- Extreme difficulty in making eye contact.
- Exhibiting other abnormal intersocial behaviors.
- Loss of interest in previously pleasurable activities and withdrawal from friends and family.
Treatments for schizophrenia typically include:
- Powerful antipsychotic medications.
- Cognitive behavioral therapy.
While the severity of symptoms can vary greatly depending on the person and the situation, Katsarov notes that “it’s important to seek help when: any symptoms persist or continue to increase beyond a couple of weeks; don’t decrease to a more manageable level or resolve by using current supports and coping skills; and are interfering with daily life.”
Carmin offers some examples of how symptoms can interfere with daily life, including:
- Being fearful or too depressed to leave the house.
- Socially isolating yourself.
- Avoiding activities that you previously enjoyed.
- Experiencing intrusive, upsetting thoughts, such as hallucinations, delusions or thoughts of self-harm.
- Using alcohol or drugs to self-medicate.
Talk to a health care provider if you’re noticing that you’re doing any of these things, and reach out sooner rather than later; the longer you let symptoms go unchecked, the more your condition can progress.
Start by talking with your primary care provider, who can screen you for various mental health disorders and refer you to a specialist if necessary. A specialist may be a doctor (a psychiatrist) or nurse practitioner who can prescribe medication or another expert who specializes in therapy (such as a psychologist or licensed clinical social worker) but doesn’t prescribe medication.
Therapy visits may take place in person or online, and the COVID-19 pandemic has expanded the use of telehealth for a range of medical conditions, including mental health. Telehealth can be especially useful for “people who aren’t able to leave home or leave a job for therapy sessions,” McKernan says.
During the first few weeks of working with a therapist, “you’ll provide a lot of information about what brings you there and your history,” McKernan explains. “Then you’ll set treatment goals together and agree on a treatment plan.”
Treatment may be brief – just a few sessions – or it may be open-ended. The types of therapies or strategies you use will depend on your needs and your disorder. “For some people, a medication might be most feasible," Kaysen says. "For others, it might be psychotherapy or going back to activities that give them joy and get their bodies moving. But it all depends on the condition. The beautiful thing is that you have multiple pathways to heal.”
You also have numerous ways to reach out for help without even seeing an expert. Kaysen recommends an app from the U.S. Department of Veterans Affairs called COVID Coach. It’s a free public health tool (that doesn’t sell your data) with exercises and resources for self-care and emotional well-being beyond the pandemic.
If you only want to start with a phone call, there are lots of hotlines that can help, such as:
- The 988 Suicide & Crisis Lifeline: 988.
- The Crisis Text Hotline: Text HOME to 741741.
- The NAMI Helpline: 1-800-950-NAMI (6264).
- The Trevor Project: 1-866-488-7386.
When seeking help, remember it may take some time to find what works best but it’s worth the effort. “Mental health is crucial to overall health and well-being,” Katsarov says. “There are many ways to prioritize mental health, and it’s important to try different things until you find the best combinations of support.”
Carmin adds that mental health disorders are treatable and the social stigma that used to be associated with seeking treatment is thankfully much less currently. The bottom line, she says, is “suffering in silence is not the answer when there are effective treatments available.”